Hello, dear readers, and welcome to a bonus letters column. It has been a busy few weeks in our mailboxes, so we’ll dive right in.

-- We recently wrote about a study that poked a hole in the idea that much older adults are too frail to engage in weight training, and that due to age-related changes to their muscles, any rewards would be minimal. We heard from several readers asking for the source of the study: “Muscle Mass and Strength Gains Following Resistance Exercise Training in Older Adults 65–75 Years and Older Adults Above 85 Years” appeared in the International Journal of Sport Nutrition and Exercise Metabolism in October 2023.

For those who wish to read it, you can access the abstract and the full article online. We found it to be fascinating, and as future (fingers crossed) older adults, encouraging.

-- Many readers have had their attention caught by a column that looked at research into the idea that eating food groups in a certain order can have a beneficial effect on blood sugar. In the small study, people who ate vegetables and proteins first and saved the simple carbohydrates for last had fewer blood sugar spikes.

This prompted a question from a reader: “When saying that proteins and vegetables should be eaten before carbs, what exactly does that mean?” they asked. “Is there a time window in between parts of the meal, or should just the first couple bites be of or including protein?”

Several studies have examined this idea. In the research we cited, there was a 10-minute window between consuming the vegetable and protein part of the meal and eating the simple carbs. The thinking is that fiber in vegetables, which are complex carbs, helps slow digestion and absorption. This, in turn, eases blood sugar spikes that simple carbs can cause.

-- We recently discussed Bell’s palsy, a neurological disorder that causes sudden weakness or paralysis on one side of the face. The result is that the eyebrow and side of the mouth droop and the muscles of the cheek sag. The person may be unable to close the eyelid on the affected side. The exact causes of Bell’s palsy are not yet understood, but a connection to immune system function is suspected.

This prompted a comment from a reader: “One of the most common causes of Bell’s palsy in the northeast is Lyme disease,” they wrote. “It was not mentioned in the article and is usually treated with antibiotics.”

Lyme disease, which is caused by the bite of an infected black-legged tick, can cause inflammation that affects the peripheral or central nervous systems. You are correct that when the cranial nerves are involved, the droop known as “palsy” can occur. This is frequent enough that when patients present with Bell’s palsy, health care providers in the northeast are being urged to consider the possibility of a Lyme infection.

Thank you, as always, to everyone who took the time to write. Seeing our mailboxes fill up makes us happy. We will be back with more of your questions and comments in the regular monthly letters column.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: My sister-in-law is 82 years old and was recently diagnosed with melanoma. She has an appointment for treatment in a couple of weeks. I thought this was a serious and deadly disease. Can a patient wait long periods of time before treatment? I am surprised by the lack of alarm in this case.

Dear Reader: You are correct that melanoma, which is a form of skin cancer, is potentially deadly. This is due to how quickly this cancer grows and how aggressively it can spread. Although melanoma accounts for just 1% of all skin cancers, it causes the majority of deaths from skin cancer. The good news is that, when it is caught early, melanoma is highly treatable. The data show that the five-year survival rate in people with localized disease, which has not spread to nearby lymph nodes, is 99%.

For those who are not familiar, melanoma develops in cells known as melanocytes. These are specialized cells that produce a brown pigment known as melanin. Melanocytes are found in several areas throughout the body. This includes the skin, hair follicles and the iris of the eye, where they contribute to coloration. Melanocytes can also grow in clusters, forming moles that can appear anywhere on the body. The majority of moles are benign. However, a small percentage can develop cancerous cells.

When melanoma is suspected, something known as an excision biopsy is performed. This is the surgical removal of the cancerous area, along with a margin of surrounding tissue. It is possible, when a lesion is too large or is poorly situated, that just a portion of the tissue will be removed. If it appears that the melanoma has begun to metastasize, or spread, a test of the cells in the nearby lymph nodes, known as fine-needle aspiration, will also be performed. The tissues that have been collected are then sent to a lab to be examined by a pathologist under a microscope.

To know if the speed at which your sister-in-law is being treated is appropriate, information about staging is needed. This is a system used to identify the severity of the disease. For melanoma, stages indicate the depth to which the cancer has penetrated the skin, whether it has spread beyond the original site and, if so, how far it has spread. Staging begins with “melanoma in situ,” or Stage 0. This is cancer that is confined to the topmost layer of the skin. It escalates to Stage 4, which is disease that has spread to distant areas of the body.

For melanoma in situ, treatment consists of the excision biopsy used to diagnose the condition, which completely removes the diseased tissue. If the cancer has penetrated deeper layers of skin, a follow-up excision, along with the removal and examination of nearby lymph nodes, is likely to be scheduled. With metastatic disease, radiation, chemotherapy or immunotherapy are typically recommended.

If you are concerned that your sister-in-law is not receiving speedy care, urge her to gather her medical records and seek out a second opinion from a dermatologist or oncologist with a specialty in melanoma.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Kansas City, MO 64106; 816-581-7500

Dear Doctors: I am going to have a major abdominal surgery. My doctor says it is likely that I will be needing strong pain medications after. My question is about opioids: How long can you take them and not get addicted? What is the best way to stop so you don’t have side effects?

Dear Reader: Opioids are a class of drugs whose primary use is to treat pain that is moderate or severe. They work by binding to receptors in the brain and the body, which eases the intensity of pain signals received by the brain. Opioids also suppress certain chemical reactions in the cough center of the brain stem, making them effective for managing severe or chronic cough. And because opioids activate receptors that slow the progress of food moving through the gut, they are sometimes used to manage severe diarrhea.

Unfortunately, as the crisis of the opioid epidemic illustrates, these drugs are highly addictive. As they confer the medical benefits we discussed, they activate reward centers of the brain. This produces feelings of euphoria and profound well-being that people can come to crave. At the same time, the body is building up a tolerance to the drugs. This creates a feedback loop in which increased usage delivers diminishing rewards. Longtime use of opioids actually alters the working of the brain’s reward system, eventually making the drugs the only thing that allows the user to feel pleasure. All of this means the safe use of opioids requires careful consideration, advance planning and ongoing oversight.

Taking opioid medications for a week or less typically does not create a problem. You should be able to stop the drugs without physical side effects. It is important to use them exactly as prescribed, and never increase dosage or frequency. If longer-term use has proven necessary, your doctor should craft a taper schedule to ease off the drugs. This involves a planned series of gradually decreased dosages, during which you monitor pain levels and side effects. During this process, patients are often also switched to alternative, nonopioid pain medications. Research shows that including drug-free treatments -- such as acupuncture, physical therapy, mindfulness practices and meditation -- is also very helpful.

Physical symptoms when weaning off opioids can include anxiety, irritability, restlessness, nausea, abdominal discomfort, muscle cramps or spasms, chills, night sweats, rapid heartbeat, changes to blood pressure and poor or disordered sleep. Stopping the drugs can adversely affect the emotions and increase the risk of suicidal thoughts.

When ending opioid use that lasts more than a week to 10 days, it is very important to closely adhere to the prescribed taper plan. Immediately discuss any difficulties with your doctor. This includes both physical side effects and any signs of dependence. Your medical team can make appropriate adjustments to the taper plan, including alternative medications, to help ensure your success in stopping the opioid drug.

Finally, it is important to understand that alternative pain management programs exist. If you are not comfortable using opioids for post-surgical pain, make this clear to your medical team and ask to explore a different approach.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Kansas City, MO 64106; 816-581-7500